Please cite this publication as: Colombo, F., et al. (2011), Help Wanted?: Providing and Paying for Long-Term Care, OECD Health Policy Studies, OECD Publishing. http://dx.doi.org/10.1787/9789264097759-en This work is published on the OECD iLibrary, which gathers all OECD books, periodicals and statistical databases. Visit www.oecd-ilibrary.org, and do not hesitate to contact us for more information. Help Wanted? PROVIDING AND PAYING FOR LONG-TERM CARE As life expectancy pushes into the late 70s for men and well into the 80s for women, ever more people want help in order to be able to live their lives to the full for as long as possible. How will demographic and labour market trends affect the supply of family, friends and care workers available to the elderly? Will public nances be threatened by the future costs of care? What should be the balance between private responsibility and public support in care giving? This book addresses these and other important questions. TABLE OF CONTENTS Chapter 1. Long-term Care: Growing Sector, Multifaceted Systems Chapter 2. Sizing Up the Challenge Ahead: Future Demographic Trends and Long-term Care Costs Chapter 3. The Impact of Caring on Family Carers Chapter 4. Policies to Support Family Carers Chapter 5. Long-term Care Workers: Needed but Often Undervalued Chapter 6. How to Prepare for the Future Long-term Care Workforce? Chapter 7. Public Long-term Care Financing Arrangements in OECD Countries Chapter 8. Private Long-term Care Insurance: A Niche or a “Big Tent”? Chapter 9. Where To? Providing Fair Protection against Long-term Care Costs and Financial Sustainability Chapter 10. Can We Get Better Value for Money in Long-term Care? “WHO recognizes that long-term care represents a major challenge for all countries in the world, with important implications for economic development and for the health and well-being of older people. This well-documented book provides a comparative analysis of the common challenges and diverse solutions OECD countries are adopting to respond to the growing demand for long-term care services, and particularly its implications for nancing and labour markets. It provides much needed evidence to guide policy makers and individuals.” Dr. John Beard, Director, Department of Ageing and Life Course, World Health Organization “This carefully researched book offers invaluable data and insights into the organization and nancing of long-term care in OECD countries. The book is an indispensable resource for anyone interested in international long-term care.” Dr. Joshua M. Wiener, Distinguished Fellow and Program Director of RTI’s Aging, Disability, and Long-Term Care Program, United States www.oecd.org/health/longtermcare ISBN 978-92-64-09758-2 81 2011 03 1 P -:HSTCQE=U^\Z]W: Help Wanted? PROVIDING AND PAYING FOR LONG-TERM CARE Help Wanted? PROVIDING AND PAYING FOR LONG-TERM CARE With the financial assistance of the European Union Help Wanted? PROVIDING AND PAYING FOR LONG-TERM CARE Francesca Colombo, Ana Llena-Nozal, Jérôme Mercier, Frits Tjadens This work is published on the responsibility of the Secretary-General of the OECD. The opinions expressed and arguments employed herein do not necessarily reflect the official views of the OECD or of the governments of its member countries or those of the European Union. ISBN 978-92-64-09758-2 (print) ISBN 978-92-64-09775-9 (PDF) Series: OECD Health Policy Studies ISSN 2074-3181 (print) ISSN 2074-319X (online) The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of international law. Photo credits: Cover © Alexandre Lukin/Shutterstock.com. Corrigenda to OECD publications may be found on line at: www.oecd.org/publishing/corrigenda. © OECD 2011 You can copy, download or print OECD content for your own use, and you can include excerpts from OECD publications, databases and multimedia products in your own documents, presentations, blogs, websites and teaching materials, provided that suitable acknowledgment of OECD as source and copyright owner is given. All requests for public or commercial use and translation rights should be submitted to rights@oecd.org. Requests for permission to photocopy portions of this material for public or commercial use shall be addressed directly to the Copyright Clearance Center (CCC) at info@copyright.com or the Centre français d’exploitation du droit de copie (CFC) at contact@cfcopies.com. Please cite this publication as: Colombo, F. et al. (2011), Help Wanted? Providing and Paying for Long-Term Care, OECD Health Policy Studies, OECD Publishing. http://dx.doi.org/10.1787/9789264097759-en FOREWORD HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 3 Foreword There comes a time in many people’s lives when their functional and physical abilities decline. To continue to live an active and fulfilling life, people need help – from family, friends, or from people employed to help. This report is about how countries can provide that help. Most caring is provided by family and friends out of love or duty. Some additional support to such carers can have a big effect, at relatively low cost. Workers to fill caregiving jobs can be found, as long as policy makers and employers take steps to improve the dismal image of caregiving as being low-paid, hard, and low-skilled. Providing adequate financial protection for those needing care is possible, in a way that does not unduly stretch public financing. But getting these policies right needs to start now, because the challenge to implementing sustainable, responsive and fair long-term care policies is only going to get bigger and bigger, as populations age. Learning from other countries’ experiences, both good and bad, might save much money and grief. This book is the result of a two-year project conducted between 2009 and 2010 by the OECD Health Division and Social Policy Division. The study points to key polices and strategies that can help address future demand for care and respond to the implications this will have for long-term care workforce and financing. It highlights examples of useful country experiences, but it also warns about the dearth of evidence on cost-effective policies in a number of areas, making a strong plea for advancing evidence-based research on long-term care (LTC). The study used a mix of quantitative and qualitative methods. Qualitative information was collected through a fact-finding and policy questionnaire covering 29 OECD countries, complemented by selected country missions. Quantitative data were gathered from OECD databases and longitudinal surveys on health, retirement and ageing in Europe, Australia, the United States, the United Kingdom, and Korea. Projections of LTC costs were based on an update and expansion of earlier projections by the OECD and the European Commission. ACKNOWLEDGEMENTS HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 4 Acknowledgements This book is the result of work undertaken at OECD and the product of truly concerted efforts between the OECD Secretariat, governmental delegates and experts from many OECD countries. Within the OECD Secretariat, two Divisions of the Directorate for Employment, Labour and Social Affairs – the Health Division and the Social Policy Division – collaborated on the project. The report was developed by Francesca Colombo, who acted as project leader, and by Ana Lena Nozal, Jérôme Mercier and Frits Tjadens. Lihan Wei provided statistical and research assistance throughout the project. Many interns contributed to the analysis and drafting process at various stages, especially Margarita Xydia-Charmanta, as well as Katerina Gousia, Elizabeth Sugarman, Y-Ling Chi, Anna-Mari Viita and Lilian Chi Yan Li. The report benefited from invaluable comments and suggestions especially from Mark Pearson, Monika Queisser and John Martin, as well as Rie Fujisawa and Jonathan Chaloff. Many thanks also to Marlène Mohier for her editorial contribution in preparing the document for publication and to Judy Zinneman for assistance. The project would not have been possible without the help of country experts and delegates, including representatives from Health and Social Policy Ministries in OECD countries, who provided technical input, background information, and feedback. An expert meeting discussed the draft report on 15-16 November 2010 in Paris. Comments on the report were also received from the European Commission, the World Health Organization, and the Business and Industry Advisory Committee to the OECD (BIAC). The project was supported by a grant from the Directorate General for Health and Consumers Affairs of the European Commission. It benefited from voluntary contributions from Belgium, France, Japan and the Netherlands. TABLE OF CONTENTS HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 5 Table of Contents Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 1. Long-term Care: Growing Sector, Multifaceted Systems . . . . . . . . . . . . . . . 37 1.1. Scope of this report: How do OECD societies address the growing need for long-term care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.2. What is long-term care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 1.3. Who uses formal LTC services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1.4. Who provides long-term care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1.5. Who pays for long-term care, in what settings and at what cost?. . . . . . . . . . 46 1.6. What services are provided? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 1.7. How did countries get here? Where are they going? . . . . . . . . . . . . . . . . . . . . . 54 1.8. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Chapter 2. Sizing Up the Challenge Ahead: Future Demographic Trends and Long-term Care Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 2.1. Future demographic trends: Growing LTC demand . . . . . . . . . . . . . . . . . . . . . . 62 2.2. The pool of family carers is likely to decrease . . . . . . . . . . . . . . . . . . . . . . . . . . 64 2.3. How much will long-term care cost? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 2.4. Conclusions: Policies to address future pressures on long-term care systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Chapter 3. The Impact of Caring on Family Carers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 3.1. Addressing caring responsibilities: The impact on informal carers . . . . . . . . 86 3.2. Most carers are women, care for close relatives and provide limited hours of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 3.3. High-intensity caring can lead to reduced rates of employment and hours of work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 3.4. For those of working age, caring is associated with a higher risk of poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 3.5. Intensive caring has a negative impact on mental health. . . . . . . . . . . . . . . . . . 97 3.6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 TABLE OF CONTENTS HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 6 Annex 3.A1. Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Annex 3.A2. Additional Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Annex 3.A3. Estimating the Impact of Caring on Work Characteristics of Carers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Annex 3.A4. How to Measure the Impact of Caring on Wages . . . . . . . . . . . . . . . . . 120 Chapter 4. Policies to Support Family Carers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 4.1. Improving carers’ role and wellbeing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 4.2. Helping carers combine caring responsibilities with paid work. . . . . . . . . . . . . . 122 4.3. Improving carers’ physical and mental wellbeing . . . . . . . . . . . . . . . . . . . . . . . 127 4.4. Compensating and recognising carers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 4.5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Annex 4.A1. Summary Table: Services for Carers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Annex 4.A2. Leave and Other Work Arrangements for Carers . . . . . . . . . . . . . . . . . 141 Annex 4.A3. Financial Support for Carers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Chapter 5. Long-term Care Workers: Needed but Often Undervalued . . . . . . . . . . . . . 159 5.1. How many long-term care workers are there? . . . . . . . . . . . . . . . . . . . . . . . . . . 160 5.2. Who are the LTC workers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 5.3. What are the working conditions in long-term care? . . . . . . . . . . . . . . . . . . . . 169 5.4. Foreign-born workers play a substantial and growing role in some countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 5.5. Changes in LTC policies affect LTC labour markets . . . . . . . . . . . . . . . . . . . . . . 179 5.6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Chapter 6. How to Prepare for the Future Long-term Care Workforce? . . . . . . . . . . . . 189 6.1. The future challenge for the long-term care workforce. . . . . . . . . . . . . . . . . . . 190 6.2. Improving recruitment and retention: Overview of national policies . . . . . . . 190 6.3. Ensuring an adequate inflow of long-term care workers . . . . . . . . . . . . . . . . . 193 6.4. Improving retention: Valuing work, building careers. . . . . . . . . . . . . . . . . . . . . 199 6.5. Increasing productivity among LTC workers? . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 6.6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Chapter 7. Public Long-term Care Financing Arrangements in OECD Countries . . . . 213 7.1. Collective coverage of long-term care costs is desirable on efficiency and access grounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 7.2. Public long-term care coverage for personal care can be clustered in three main groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 7.3. Even within universal systems, the comprehensiveness of coverage can vary significantly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 7.4. Different approaches but similar directions: Universalism and choice-based models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 7.5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 TABLE OF CONTENTS HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 7 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Chapter 8. Private Long-term Care Insurance: A Niche or a “Big Tent”? . . . . . . . . . . . 247 8.1. A small number of OECD countries account for the largest markets . . . . . . . 248 8.2. Market failures and “consumers myopia” explain why the private LTC insurance is small . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 8.3. Policy and private-sector initiatives to increase take up . . . . . . . . . . . . . . . . . . 253 8.4. Conclusions: Private long-term care insurance has some potentials but is likely to remain a niche product. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Chapter 9. Where To? Providing Fair Protection Against Long-term Care Costs and Financial Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 9.1. Why provide financial protection against long-term care cost?. . . . . . . . . . . . 264 9.2. Improving protection against catastrophic care cost calls for universal LTC entitlement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 9.3. Universal care does not exclude targeting: What benefits and for whom? . . 266 9.4. Board and lodging costs in institutions are the main costs that LTC users face. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 9.5. Matching care need with finances: Policies for the future . . . . . . . . . . . . . . . . 278 9.6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 Chapter 10. Can We Get Better Value for Money in Long-term Care? . . . . . . . . . . . . . . . 295 10.1. What is value for money in long-term care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 10.2. Towards more efficient delivery of long-term care. . . . . . . . . . . . . . . . . . . . . . . 296 10.3. Is it possible to optimise health and care?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 10.4. Addressing long-term care systems governance . . . . . . . . . . . . . . . . . . . . . . . . 315 10.5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 Tables 1.1. Cash-for-care schemes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 1.2. Selected LTC policy changes over the past ten years in OECD countries at a glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 2.1. Public LTC expenditure expected to rise significantly by 2050. . . . . . . . . . . . . . . 74 2.2. Potential impact of changing the mix of public/private financing of LTC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 3.1. Unpaid care is mostly directed towards parents and spouses. . . . . . . . . . . . . . . 90 3.2. Carers are more likely to be home makers, less likely to be employed . . . . . . . 92 4.A1.1. Summary Table: Services for carers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 4.A2.1. Leave and other work arrangements for carers . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 4.A3.1. Financial support for carers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 TABLE OF CONTENTS HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 8 5.1. Evidence on ageing of the LTC workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 5.2. Initial training levels for the lower-level LTC workforce across the OECD . . . . . 166 5.3. Wages in LTC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 5.4. Foreign-born care workers in LTC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 6.1. Workforce policies to increase the supply of LTC services . . . . . . . . . . . . . . . . . . 191 7.1. Public LTC coverage: A summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 7.2. Universal long-term care insurance schemes in OECD countries . . . . . . . . . . . . 221 7.3. Long-term care need assessment process in selected OECD countries . . . . . . . 232 7.4. Approaches to covering board and lodging cost (B&L) in nursing homes in OECD countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 9.1. Household composition of net-worth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 10.1. Policies to improve value for money in long-term care in OECD countries: An overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 10.2. Policies to promote home care in OECD countries. . . . . . . . . . . . . . . . . . . . . . . . . 299 10.3. Policies to avoid the inappropriate use of acute care services and co-ordinate LTC programmes in OECD countries . . . . . . . . . . . . . . . . . . . . . . 308 10.4. Average length of stay for dementia and Alzheimer’s disease in acute care (in days) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310 Figures 1.1. Financial sustainability is the most important policy priority for LTC systems in the OECD, 2009-10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 1.2. More LTC users receive care at home than in institutions . . . . . . . . . . . . . . . . . . 40 1.3. Most LTC users are women aged over 80 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 1.4. Approximately half of all LTC users are aged over 80 years . . . . . . . . . . . . . . . . . 41 1.5. Younger LTC users receive higher amounts of home care than the very old ones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 1.6. LTC workers represent a small share of the working-age population, 2008. . . . 45 1.7. The size of the LTC workforce is limited compared to the number of those in need. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 1.8. The share of public LTC expenditure is higher than that of private LTC expenditure in OECD countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 1.9. Spending on LTC in institutions is higher than spending at home in OECD countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 1.10. Significant variation in LTC expenditure among OECD countries . . . . . . . . . . . . 49 1.11. High LTC expenditure is associated with high LTC-worker density . . . . . . . . . . 49 2.1. The share of the population aged over 80 years old will increase rapidly . . . . . 62 2.2. The shares of the population aged over 65 and 80 years in the OECD will increase significantly by 2050 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 2.3. The share of the working-age populations is expected to decrease by 2050 . . . 64 2.4. The very old-age dependency ratio is increasing rapidly . . . . . . . . . . . . . . . . . . . 65 2.5. More surviving old men for each woman by 2050 . . . . . . . . . . . . . . . . . . . . . . . . . 68 2.6. Increase in the proportion of old people living in couples, by 2050 . . . . . . . . . . 68 2.7. The proportion of frail elderly either living alone or with a frail partner will decrease, but the share of both-frail couples will increase by 2050. . . . . . . 69 2.8. The projected growth in frail elderly greatly outweighs that of potential caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 TABLE OF CONTENTS HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 9 2.9. The average annual growth of LTC expenditure will be significantly higher than real projected GDP growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 2.10. The demand for LTC workers is expected to at least double by 2050 . . . . . . . . . 77 2.11. Change in demand for LTC workers and working-age population by 2050 . . . . 78 3.1. Caregiving varies by country and type of help provided. . . . . . . . . . . . . . . . . . . . 88 3.2. Informal carers are predominantly women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 3.3. Carers tend to provide limited hours of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 3.4. Persons with more ADL limitations require more care . . . . . . . . . . . . . . . . . . . . . 91 3.5. Carers work fewer hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 3.6. Informal caring results in a lower probability of employment . . . . . . . . . . . . . . 94 3.7. Informal carers reduce their working hours when at work . . . . . . . . . . . . . . . . . 95 3.8. Carers are more likely to stop working rather than work part-time . . . . . . . . . . 96 3.9. Unpaid caring leads to lower income but not necessarily lower wages . . . . . . . . 98 3.10. More mental health problems among carers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 3.11. Mental health problems depend on the intensity of caring . . . . . . . . . . . . . . . . . 100 3.12. Caregiving leads to higher chances of mental health problems . . . . . . . . . . . . . 102 3.A2.1. Higher care intensity and co-residential care have a stronger negative impact on employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 3.A2.2. Higher care intensity and co-residential care have a stronger negative impact on hours of work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 3.A2.3. Higher care intensity and co-residential care have a stronger negative impact on mental health problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 3.A2.4. Intensive carers more likely to be older and more disadvantaged . . . . . . . . . . . 115 4.1. Care leave is less frequent than parental leave . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 4.2. More mothers than family carers among part-time workers. . . . . . . . . . . . . . . . 125 4.3. Care leave and part-time work is more likely in certain sectors . . . . . . . . . . . . . 126 4.4. Carer’s allowances generate incentives to reduce work hours . . . . . . . . . . . . . . 134 5.1. Higher ratio of LTC users per full-time equivalent worker in home care than in institutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 5.2. Less than half of LTC workers are in home care in most OECD countries . . . . . 161 5.3. Most LTC workers are women. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 5.4. Part-time work is more frequent in home-care settings. . . . . . . . . . . . . . . . . . . . 162 5.5. In most OECD countries, less than half of the LTC workforce consists of nurses, mostly employed in institutional settings . . . . . . . . . . . . . . . . . . . . . . 164 5.6. Employment of foreign-born in health and other community services and households. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 7.1. Users of LTC services vary significantly across the OECD. . . . . . . . . . . . . . . . . . . 223 7.2. Variation in LTC expenditure is not strongly correlated to the share of the population aged over 80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 7.3. Long-term care expenditures by sources of funding, 2007 . . . . . . . . . . . . . . . . . . 231 7.4. Comprehensiveness of public LTC coverage across the OECD, 2008 . . . . . . . . . . 238 8.1. The private LTC insurance market is small. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 9.1. The cost associated with low-care need is significant for low-income seniors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 9.2. The cost associated with high-care need is significant for most seniors. . . . . . 265 9.3. Disposable income falls with age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 9.4. Public transfers provide the bulk of income in old age . . . . . . . . . . . . . . . . . . . . . 272 [...]... administrations HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 17 Help Wanted? Providing and Paying for Long-Term Care © OECD 2011 Summary and Conclusions Help Wanted? Providing and Paying for Long-Term Care 1 The growing need for long-term care has significant financing and labour-market implications Long-term care need is growing in line with population ageing… With population ageing,... cost-effectiveness of home care for high-need users requiring round-the-clock care and supervision, and for users residing in remote areas with limited home -care support In 2008, institutional care accounted for 62% of total LTC costs across OECD countries, while on average only a third of LTC users received care in institutions HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 EXECUTIVE SUMMARY... current value of a home minus outstanding home-secured debt The loan does not have to be repaid as long as the borrower continues to live in the home and it generally becomes due when the borrower dies, sells the home, or permanently moves out of the home 12 HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 Help Wanted? Providing and Paying for Long-Term Care © OECD 2011 Executive Summary What... solely on an in-kind system (Australia, Hungary, Japan and Mexico) Many provinces and HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 21 SUMMARY AND CONCLUSIONS territories in Canada have well-established self-managed care schemes, providing eligible users with cash benefits to manage care delivery, including by paying family carers and friends Cash benefits paid to the care recipients... co-ordination remain The co-ordination of care within LTC systems and across health and long-term care deserves considerable policy attention in the future An overall vision of health and long-term care could lead to gains in management Governance of long-term care is often complex As the discussion on care co-ordination suggested, LTC services and settings are difficult to manage Long-term care policies interact... community-based, prevention-oriented LTC 34 HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 SUMMARY AND CONCLUSIONS benefit targeted at low -care- needs seniors In 2008, Germany introduced carrot -and- stick financial incentives based on sickness funds success with rehabilitation and management of users’ transition from institutions to lower -care settings However, such innovations are rare and there is... friends HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 SUMMARY AND CONCLUSIONS ● For the carer, because carers provide care out of love or duty, despite the fact that they incur economic, health and social consequences as a result ● And for the public finances, because supporting the supply of family care can help maintain the public, formal parts of the system, affordable The estimated... institutional, home-based, and community services, and good partnership between formal and informal care systems Future demands for care will put higher pressure on governments and the private sector to deliver high-performing long-term care services Setting the public and private financing mix and organising formal workforce supply are key elements that all governments need to address Models and approaches... settings, and setting up co-ordination tasks to guide users through the care process ● Addressing institutional efficiency, such as by establishing good information platforms for LTC users and providers, setting guidelines to steer decision-making at local level, the use of care planning processes, and data sharing within government administrations HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD. .. International research and collaboration on value for money and the development of measures or indicators of efficiency in LTC deserve much priority 32 HELP WANTED? PROVIDING AND PAYING FOR LONG-TERM CARE © OECD 2011 SUMMARY AND CONCLUSIONS Encouraging home care is desirable for users but in certain conditions institutional care is more cost-effective How to balance home and institutional care settings is . States www .oecd. org /health/ longtermcare ISBN 97 8-9 2-6 4-0 975 8-2 81 2011 03 1 P -: HSTCQE=U^]W: Help Wanted? PROVIDING AND PAYING FOR LONG-TERM CARE Help Wanted? PROVIDING. administrations. Help Wanted? Providing and Paying for Long-Term Care © OECD 2011 19 Summary and Conclusions Help Wanted? Providing and Paying for Long-Term Care 1.